CATARACT

By: Esther Joanna J. Ricamara Student Nurse Institute of Nursing St. Josephs College of Quezon City

STRUCTURE OF THE LENS

The lens is a biconvex, transparent, avascular structure with no nerve supply. It measures 9mm by 4mm in diameter. The lens lies behind the iris and in front of vitreous. It is supported by the zonules or suspensory ligaments, which attach it to the ciliary processes. The lens has an elastic capsule, which enables it to change shape during accommodation. This capsule is semipermeable to water and electrolytes. The lens is receives its nourishment from the aqueous humour.

Composition of Lens The lens is 65% water and 35% protein. In addition, there are trace minerals, the most important being sodium, potassium and calcium.

Cataract is a clouding , or opacity of the lens that leads to blurring of vision and eventual loss of sight. The opacity of the lens is caused by chemical changes in the protein of the lens because of the slow degenerative changes of age, injury, poison or intraocular infection. Cataract is the No. 1 eye disease that causing blind. 46% blindness is caused by cataract. Cataracts occur so often in the aged. At 80 years of age, about 85% of all people have some clouding of the lens.

TYPES OF CATARACTS
Cataracts that affect the center of the lens (nuclear cataracts). A nuclear cataract may at first cause you to become more nearsighted or even experience a temporary improvement in your reading vision. But with time, the lens gradually turns more densely yellow and further clouds your vision. As the cataract slowly progresses, the lens may even turn brown. Advanced yellowing or browning of the lens can lead to difficulty distinguishing between shades of color.

Cataracts that affect the edges of the lens (cortical cataracts). A cortical cataract begins as whitish, wedge-shaped opacities or streaks on the outer edge of the lens cortex. As it slowly progresses, the streaks extend to the center and interfere with light passing through the center of the lens. People with cortical cataracts often experience problems with glare.

Cataracts that affect the back of the lens (posterior subcapsular cataracts). A posterior subcapsular cataract starts as a small, opaque area that usually forms near the back of the lens, right in the path of light on its way to the retina. A posterior subcapsular cataract often interferes with your reading vision, reduces your vision in bright light, and causes glare or halos around lights at night.

Cataracts you're born with (congenital cataracts). Some people are born with cataracts or develop them during childhood. Such cataracts may be the result of the mother having contracted an infection during pregnancy. These cataracts also may be due to certain conditions, such as myotonic dystrophy, galactosemia, Lowe's syndrome or rubella. Congenital cataracts don't always affect vision, but if they do they're usually removed soon after detection.

Anterior Pole Cataract May present as a congenital (autosomal dominantly inherited) or acquired cataract secondary to uveitis or trauma (associated with anterior subcapsular opacities).
Clinical

features:

Symptoms: may or may not cause a significant visual disturbance. Signs: Small anterior polar opacification usually is sharply defined

Lamellar Cataract common, bilateral and symmetrical, round, gray shell of opacity that surrounds a clear nucleus; usually dominantly inherited cataract, which may have a metabolic or inflammatory cause. Fibers become opacifed in response to a specific insult during their most active metabolic stage and are pushed deeper into the cortex as normal lens fibers are laid down around it.

DEGREES OF CATARACT
Immature Cataract part of the lens is opaque. Mature Cataract the whole lens is opaque and may be swollen (intumescent) Hypermature Cataract the lens becomes dehydrated because water has escaped from the lens, leaving an opaque lens and wrinkled capsule. Phacolytic Cataract (lens) lens matter leaks out causing uveitis and secondary glaucoma. Cataracts should be extracted before this situation arises.

CLASSIFICATION OF
CATARACTS

CONGENITAL CATARACTS

Babies are sometimes born with cataracts as a result of an infection, injury, or poor development before they were born, or they may develop during childhood. Causes: Rubella or malnutrition in the first trimester of pregnancy results in a lamellar cataract in the baby. Abnormal development of the eye in the fetus causes pressure on the anterior pole, resulting in an anterior pole cataract. A tag of a hyaloid membrane remaining from fetal life can result in a posterior pole catatact (the hyaloid artery runs from the retina to the lens during fetal life.

Congenital cataracts are noted at birth, infantile cataracts occur in the first year, and juvenile cataracts develop during the first 12 years of life. About one third of all congenital cataracts are hereditary and unassociated with any other metabolic or systemic disorders. Trisomy 21, or Downs syndrome, is the most common autosomal trisomy, with an incidence of 1 per 800 births. Systemic features include mental retardation, stunted growth, mongoloid facies, and congenital heart defects. Ocular features include visually disabling lens opacities in 15% of cases, narrow and slanted palpebral fissures, blepharitis, strabismus, nystagmus, light-colored and spotted irides (Brushfield spots), keratoconus, and myopia. Cataract is also associated with trisomy 13 (Pataus syndrome), trisomy 18 (Edwards syndrome), and Cri du chat syndrome

SIGNS OF CATARACT IN A BABY OR CHILD

A white pupil may be noted. It may be unilateral or bilateral.

Changes in childs behavior such as loss of concentration as they cannot follow word or pictures. Inability to catch a toy (ex. Ball) because of loss of depth perception. A squint (strabisnus) will indicate that there is a problem in the visual pathway preventing the sight from developing.

AGE-RELATED CATARACTS

As the name suggests, this type of cataract develops as a result of aging. Age related cataract occur at the age of 60 yrs. They result from sclerosis of the lens due to degenerative process. The rate of progression varies. It is usually bilateral condition, one eye being affected before the other. The cataract is either nuclear and cortical. A nuclear cataract affects the central lens and takes on brown color. In this instance the patient sees better in dim light when the pupil is dilated and the light rays can center the eye around the central opacity. Mydriatics can be given to dilate the pupil and given to dilate the pupil and give some vision around the cataract.

A cortical cataract affects the periphery of the lens and looks white. This type of cataract can produce a uni-ocular diplopia as the opacity splits the light. Vision is better in bright light when the pupil constricts and so reduces the peripheral distortion.

TRAUMATIC CATARACT

Blunt trauma, which does not result in rupture of the capsule, may cause an anterior and/or posterior subcapsular cataract, or both. Initially, fluid influx causes swelling and thickening of the lens fibers. Later the fibers become less swollen; the anterior subcapsular region whitens and may develop a characteristic flowershaped pattern or an amorphous or punctuate opacity. If the capsule is ruptured, it usually ruptures posteriorly; the lens is rapidly hydrated forming a white cataract. A small capsular penetrating injury may result in localized lens opacity. A larger rupture results in rapid hydration and complete opacification. Penetrating injuries can be caused by accidental or surgical trauma such as a peripheral iridectomy or during a vitrectomy. Electric shocks as a result of lightning or an industrial accident cause coagulation of proteins or osmotic changes that can also cause cataract.

TOXIC CATARACT

Toxic substances can affect the metabolism of the lens and cause opacity formation. Radiation and some drugs have this effect.

CATARACT SECONDARY TO EXISTING EYE

DISEASES

Glaucoma, retinitis pigmentosa, retinal detachments, retinophaties, choroiditis and uveitis upset the metabolism of the lens, causing cataract formation. The opacities form in the posterior subcapsular area, eventually involving the entire lens.

CATARACT ASSOCIATED WITH SYSTEMIC

DISEASE Some systemic diseases cause an upset in the metabolism of the lens, causing, in the main, posterior sub-capsular opacities. Diabetes mellitus Type 1 and Type 2: the increased glucose level in the aqueous humour is taken up by the lens disturbing its metabolism. Cataracts can occur with rapid onset in juvenile diabetics, the lens becoming completely opaque within several weeks. In older diabetic patients opacities are nuclear, posterior sub-capsular or cortical in nature and take longer to develop.

Hypoparathyroidism: cataract formation from this cause is usually seen after the removal of the parathyroid glands during thyroid gland removal. It can be idiopathic. Low calcium levels disturb the lens metabolism. Both the skin and the lens share a common embryological origin, the ectoderm. Therefore, skin disorders may be associated with cataract formation. Atopic dermatitis and eczema may affect any part of the body, especially the limb flexures. Cataract develops in some atopic adults, usually as a bilateral, rapidly progressive shield cataract. This is a dense, anterior subcapsular plaque with radiating cortical opacities, and wrinkling of the anterior capsule because of localized proliferation of lens epithelium. Posterior subcapsular opacities may also occur.

ASSESSMENT
Cataracts usually form slowly and cause few symptoms until they noticeably block light. When symptoms are present, they can include: Vision that is cloudy, blurry, foggy, or filmy Progressive nearsightedness in older people often called "second sight" because they may no longer need reading glasses. Changes in the way you see color because the discolored lens acts as a filter. Problems driving at night such as glare from oncoming headlights. Problems with glare during the day. Double vision (like a superimposed image). Sudden changes in glasses prescription.

Vision Abnormality
Color vision deviation

glare

visual field loss

PATHOPHYSIOLOGY Predisposing Factors: Metabolic Disturbance & Osmotic Regulation Failure (Malnutrition) Decrease Crystallins Toxic Trauma/Injury Precipitating Factors: Congenital Oxidation due to aging ( Age of 60 and above)

METABOLIC DISTURBANCE & OSMOTIC REGULATION FAILURE (MALNUTRITION)

The lens maintains ion defferentials between intra and extracellular fluids (increase K, decrease Na internally and decrease K, increase Na externally) via Na-K ATPase Pump. Pump inactivation cause increase intracellular osmolality which with membrane leakiness results in localized water accumulation and light scatter due to opacity.

TOXIC

Topical, inhaled, and systemically administered steroids can cause posterior subcapsular cataracts. Direct interaction of steroids may affect their function, e.g., steroid alteration of Na+,K+-ATPase may cause sodium-potassium pump inhibition affecting osmotic regulation. Steroids may stimulate crystallin conformational changes causing aggregation and may affect intracellular Ca homeostasis causing protein bonding. Alteration of calcium levels disturb the lens metabolism causing that can cause changes in osmolality in the lens and eventually results in water accumulation that cause opacity.

DECREASE CRYSTALLINS
Our lens is made up of 35% Crystallins (are water soluble proteins) One of the function of Crystallins is to prevent the lens proteins to precipitate. Decreased crystallin levels cause proteins to precipitate, which leads to cataract formation. Phase separation of proteins refers to the hydrophobic aggregation of lens proteins causing reversible protein rich and poor regions in the lens fibers, which results in light scatter or opacity.

OXIDATION DUE TO AGING ( AGE OF 60 AND ABOVE)

Oxidation is a key feature in the pathogenesis of most cataracts and low oxygen levels (O2) are important for maintaining a clear lens. There is a sudden oxygen gradient from the outer part of the lens to the center. Mitochondria in the lens cortex remove most of the oxygen, thus keeping nuclear O2 levels low. In older people mitochondrial function diminishes and superoxide production by the mitochondria increases resulting in increased nuclear oxygen and superoxide levels. In these process the lens becomes opaque.

DIAGNOSTIC TEST:

An eye exam will be given to test how well the patient can see (remember to bring the glasses or wear the contacts during eye examination). The doctor will dilate the pupil in order to examine the condition of the lens and other parts of the eye. B Scan is an ultrasound scan used before cataract extractions. It gives a three dimensional picture of the eye. Showing up any abnormality in the eye, such as retinal detachment or tumor. This examination is necessary because the opthalmologist is unable to examine the fundus through an opaque lens. If a tumor or retinal detachment were noted, the lens extraction might not take place, as no improvement in vision would occur.

SURGICAL MANAGEMENT:
Surgery

is the only satisfactory treatment for cataracts. It is advised when the cataract interferes with a persons mobility and ability to carry out normal activities.

Intracapsular technique Removal of cataract within its capsule (ICCE) Extracapsular technique An opening is made in the capsule and the lens is lifted without disturbing the membrane. A person with aphakia (absence of lens) is very farsighted (hyperopic) (ECCE) Cryoextraction The cataract is lifted from the eye by a small probe that has been cooled to a temperature below zero and adheres to wet surface of the cataract.

Iridectomy Done preceeding cataract extraction to create an opening for the flow of the aqueous humor which may become blocked postop when the vitreous humor moves forward. This is to prevent secondary glaucoma. Phacoemulsion A method of cataract removal which breaks up the lens and flushes it out in tiny pieces.

Needling or Lens Aspiration is performed on an infant or child under he age of 15 years. The cortex and nucleus of the lens are irrigated out through an incision in the anterior lens capsule, leaving the posterior capsule behind in order to prevent vitreous prolapse. At this age, the lens matter is soft enough to be aspirated. The posterior lens capsule left behind often scleroses causing visual impairment when a capsulotomy will be performed using Yag laser.

ICCE And ECCE

ICCE

ECCE

Small incisional Phacoemulsification surgery

INTRAOCULAR LENS IMPLANT

Intraocular Lens implant. Is an alternative to cataract glasses and contact lenses. The lens, which is made of polylethyl methacrylate, is implanted at the time of cataract extraction; may be held in position either by suture to the iris or by implanting it into the capsular sac (The main advantage of the implanted lens is better binocular vision).

TYPICAL INJECTABLE IOL

Superflex lens: 6.25mm x 12.50mm

C-Flex lens 5.75mm x 12.00 mm

Cflex/Superflex injector

LOADING THE SUPERFLEX IOL

SUPERFLEX INSERTION

NURSING MANAGENENT:
Post Op Care The eye is covered with dressing (eyepad) and eye shield to protect it from injury. The patient is usually allowed out of bed the day following surgery. Daily changes of dressing is done. After 7 to 10 days, all dressings are usually removed. During the first month, protect the eye with a shield at night. Administer eye drops as ordered.

NON PHARMACOLOGICAL TREATMENT AFTER

SURGERY Temporary glasses may be prescribed 1 to 4 weeks after surgery. Usually within 6 to 12 weeks healing has been sufficient for fitting of permanent glasses or contact lenses. Remember: Cataract glasses (aphakic glasses) magnify so that everything appears about one fourth closer than it is. Patients need to know that it will take time to learn to judge distance, to climb stairs and do other simple things Use of contact lens improve visual correction and better cosmetic appearance.

NURSING DIAGNOSIS
Sensory/Perceptual alteration related to visual impairment Risk for self-mutilation Impaired social interaction Powerlessness Situational Low Self-esteem